5/15/2023 0 Comments Print therapy llc![]() Payment arrangements are required at the time of your visit. We cannot waive co-pays, deductibles, or coinsurance for non-covered services defined as patient responsibility under the terms of our contract with various health plans. If your insurance carrier has a specific copay amount for specialty care, you will be expected to pay this amount at the time of service. Please check with your insurance company whether or not physical therapy is considered a specialty service. Physical Therapy is classified differently based on your insurance provider. Co-pays are the patient’s responsibility and are due at the time of service. ![]() ![]() We will collect it at the time of service. If we are filing claims with your insurance company, we are contractually obligated to collect your copay. It is your responsibility to pay any deductible amount, co-insurance, or any remaining balance left unpaid by your insurance provider. This will occur if you have a deductible or co-insurance. Your payment method that is kept on file with be charged for any remaining balance not covered by insurance. If your insurance plan is one of our contracted plans, we will bill your insurance on your behalf. Financial PolicyĪscent Physical Therapy and Performance LLC contracts with several healthcare insurance programs. By clicking Agree and typing your name you are electronically signing this form. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice/ clinic’s Notice of Privacy. I understand that this information may be disclosed electronically by the Provider and/or the Provider’s business associates. I acknowledge that I have received the practice/clinic’s Notice of Privacy (Located at the top of this page), which describes the ways in which the practice/clinic may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact Ascent if I have a question or complaint. By clicking Yes and typing your name you are electronically signing this form. ![]() I understand that if I choose to revoke this Authorization, the revocation will not be effective for any uses and/or disclosures of my protected health information that have already been made in reliance on this Authorization. I agree that the Company may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content and waive any right to compensation, therefore I understand that I may revoke this authorization but only in writing delivered to the clinic office manager. I authorize the Company, to copyright, use and publish the same in print and/or electronically. I grant to Ascent Physical Therapy and Performance and its affiliated entities, and its representatives and employees (collectively the “Company”) the right to take photographs and\or videos of me in connection with my participation in physical therapy services. ![]() I hereby authorize and consent to treatments/services for myself, or on the behalf of the above-named patient, performed by the staff at Ascent Physical Therapy and Performance and/or as directed by my referring services. ![]()
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